Archive | November, 2014

Okay, I admit it. I love post-call days. There’s nothing better than knowing that while everyone else is driving to work and experiencing morning struggles, I get to drive home and snuggle under my warm blankets. I get to finally shut my brain off.

It’s really tempting to enter the door of my apartment, throw my things down, run to my bed and flop, face-first into the covers. But I find that when I do that, I don’t wake up as refreshed. I actually feel even groggier sometimes.

Recently, I’ve been trying a new thing where I take 30-60 minutes to give my body a little R&R (rest and relaxation) before I shut it off completely. Kind of like a gradual entrance into the serenity of sleep. Here is my recipe, feel free to add your own ingredients and modify as you please!

Ingredients:

1 scented candle

1 playlist

water

cucumbers, raspberries, mint or clementines

pen & paper

yoga mat

lacrosse ball/tennis ball

1 wall

RELAX (2 minutes):

First, I light a scented candle. Yeah, it sounds cheesy, but believe me – once you smell that citrusy aroma or lilac infusion, you’ll forget all about those stale hospital sheets and the scrubs you wore all night. I try to stay away from sugary scents (Bath & Body Works, I hate you) because then I’ll just abandon my routine and search my shelves for chocolate or candy and spend the next 15 minutes eating them.

After this, I also flip on my favorite playlist to set the mood. I usually try to go for some slower beats – some R&B slow jams do the job quite well.

HYDRATE (3 minutes):

This is the most important part. I grab a tall glass of cold water and drink the whole thing. Sometimes two, if I’m feeling dangerous.

Too often, we don’t drink any water while on call. Our bodies are aching to be hydrated by the time we get home.

I love slicing up some cucumbers and splashing them in the water. I also pre-make trays of ice cubes frozen with mint, raspberries or clementine slices and add them to the water. It just adds a little extra zest, and I can pretend I’m getting more vitamins.

REFLECT (5 minutes):

This is the second most important part. I write down two things:

1) One thing that I learned from the night

2) One thing I did well

The objective is to do some reflection and identify what the previous day meant to me. Writing down things I did well, also encourages me to improve for tomorrow. If you don’t encourage yourself, who will?

STRETCH (5-15 minutes):

Okay, I lied. This is equally important. I unroll my yoga mat and do 15 minutes of easy yoga. Sure, downward dog seems impossible at first, but once I get started, I find that it’s exactly what my body needs.

Now I grab my lacrosse ball and find a wall. A friend recently gifted a lacrosse ball to me, but you can also use a tennis ball. This thing is glorious. It’s an easy do-it-yourself myofascial release and releases your trigger points.

Start with your upper traps.

After spending a night slouched over hospital charts and patient’s bedsides, it is impossible not to have tight shoulders. This routine can help you prevent upper-crossed syndrome. Put the lacrosse ball between upper back and the wall. Work the ball up and down your back. Keep your arms folded in front of you, moving your shoulder blades out of the way. Here is where the R&B slow jams really start to make sense – yep, you’re grinding with the wall, but hey, no one’s watching and it feels great.

When you find a point in your back that is more sensitive or painful – stay there. Don’t move and add some more pressure against the wall. This is a trigger point. Breathe into it for several seconds. Even though it hurts at first, you’ll find that after some time, you relax into it. Do this for any points you find throughout the routine.

Now finish your entire back.

I probably don’t need to tell you to do this because you will naturally want to. Roll the lacrosse ball all the way down your back on one side of the spine. Repeat on the other side. This releases all your spinal muscles and your lats.

Don’t forget your pits.

The idea is to work the lacrosse ball where your lats insert and improve lymphatic drainage. Place it under your armpits, and with the same arm behind your head, roll the ball up and down against the wall.

Release your IT band.

Lie on your side on your yoga mat and place the lacrosse ball between your hips and the mat. Now roll so that the ball slides down the side of your thigh. Tight IT bands can cause a lot of injury and knee pain. So keep it nice and loose by doing this.

Staying on your side, work the lacrosse ball in circular motions around your hip joint. Your glutes insert here, so you want to get them good.

Release your lower extremities.

After standing all day and night, you want to release the main muscle groups of your legs and your feet.

Lying supine on your mat, work the lacrosse ball on the bulk of your glutes and your hamstring insertions. Work in circular motions around your ischial tuberosity.

Now move the ball down the back of your thigh to get your hamstrings. Work it down to your calves.

To get your hip flexors, sit in kneeling position and roll the lacrosse ball across the front of your thighs. It’s easier than trying to lie prone in plank position (nobody needs abb work at a time like this!)

In standing, put the ball under one of your feet and move it up and down. It feels amazing, trust me. Your clogs are no match for this.

Finally, it’s time to hit the sheets! My body feels like jello, but the best kind.

Posted on 29 November 2014 by Annie Li (Meds 2018), The History of Medicine Club

How do social practices fair in the face of epidemic disease?

Looking into the past, we arrive at The Plague of Athens, where a contagious and fatal disease was rampant. Determining disease etiology was highly important as it provided insight to possible remedies. The clergy believed that the plague was due to divine punishment. Others believed that the attacking Spartans had poisoned their wells. Still others said that the plague was due to the long war and starvation. When the etiology could not be identified, and no remedy effective, social structure broke down – fear, self-preservation and perhaps opportunistic gains took over.

Moving forwards, we arrive at the Black Death – a disease that produced in its victims symptoms of fever, swollen and oozing nodes, dehydration and death. At the time, Black Death was known to be spread by travellers. This caused a heightened sense of them and us. The outcome was such that not only travellers suffered cruelties, but minorities, and village idiots were also targeted. Social construct within the dominant population also broke down; the living wandered the countryside, the sick were shunned, and the dead left unburied. Furthermore, the certain fatality of this disease and the inability of any authority to remedy it shook the foundations of the feudal social system.

Further still, we arrive on North American shores where waves of European immigrants brought with them typhus and cholera. Treatment towards the immigrants was incredibly biased and unjust. Boarders lined with angry and fearful residents. Unfortunately, sick and healthy immigrants were regarded alike and were forcefully isolated and quarantined together. Inevitably, the healthy became sick and the majority of immigrants succumbed to the disease. With imported diseases, social structures dealing with the other are under strenuous stress and courtesy is unlikely to be observed.

Presently during the Ebola epidemic in West Africa, how have we faired? Fear, there is definitely plenty of that – both in Western Africa and in the Americas. In West Africa fear may be gathered from the unburied bodies, street riots and vigilant adherence to rituals. In the Americas fear is seen in futile and exaggerated precautions to this virus. Futility is seen in the implementation of thermal scans at airports, which neither accounts for the incubation period of the disease nor the other more common diseases associated with fevers abroad (e.g. malaria). Exaggerated response is seen in the suspension of basic human rights to a nurse who had returned from West Africa. Ms. Hickox and was forced to live in a tent, in a hospital, without shower and directed to wear paper scrubs. Despite this fear (which spans back to antiquity), I would argue however, that we are learning. Fear is limited by limiting the epidemic. Given our current understanding of science, epidemics are best limited by targeted and vigorous screening, isolation or quarantine and if need be, proper disposition of the body. (These elements may be seen in Nigeria’s successful response to Ebola.)

It is perhaps instinctive that during epidemics (historical or present), fear transcends established social structures. Although it seems circular, one feasible solution preventing the collapse of social constructions during epidemics is to prevent epidemics altogether. Currently, with our investment and knowledge in science, we are in a much better position to prevent epidemics than our historical counter parts.

Before we can delve into this wonderful journey of learning from Hippocrates, we must confront prejudice! Some of you may be thinking – Learning from a dead guy that was born two and a half millennia ago? He thought disease was a matter of humors! He didn’t know about germs! What can be learned? That is a good question. And I will point out two things before we continue. Firstly, if you had at all a similar reaction that followed my little script, you have belied your own ignorance as to what medicine consists of – as if knowing about germs is all it takes to make you a good doctor! But secondly, and more importantly, what can be learned from a dead guy (like over two thousand years dead!) requires us to challenge this age we live in of unprecedented chronological snobbery. That is the brilliant C.S. Lewis’ way of describing the “uncritical acceptance of the intellectual climate common to our own age and the assumption that whatever has gone out of date is on that account discredited.” In other words, because we’re so advanced today we think we are so much smarter than everyone that has lived before us. Anybody acquainted with history should have a jumpstart on avoiding this double trap of arrogance and folly. Certainly people have made mistakes in the past, and if we were in their shoes we likely would have made similar mistakes. Ironically, we have easier access to volumes of history than ever before, but it has served us little in humbling us. We must remember that great minds are great minds whether from two thousand years ago or from today. If we remember this, we can be good learners. This first blog post is dedicated precisely to that. Let’s lay down the groundwork on how to think so we can have a proper approach to Hippocrates when we come together again.

To understand Hippocrates well we must understand him in his context and not our own. This also means we need to understand how our own understanding and views are influenced by our own context. The best way to learn about this is to read some history and particularly the history of thought! Is how we think of medicine today the same way medicine was thought of fifty years ago? Five hundred years ago? Two millennia ago? While we cannot know it all, this will surely help us to read more accurately. If there is one thing we do well in our world, it is eisogesis. We import our own meanings into what others say and fail to let them speak as they intended. We chop up their words and take what we like and leave out other important parts. Sound like something you might see on TV in the news? Think again. We have done it with the Hippocratic Oath. If you went through the white coat ceremony at Schulich, you likely recited the “Hippocratic Oath.” Let’s see if you remember saying this:

I SWEAR by Apollo the physician, and Aesculapius, and Health, and All-heal, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation-

to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required;

to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation;

and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others.

I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.

I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion. With purity and with holiness I will pass my life and practice my Art.

I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work.

Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further from the seduction of females or males, of freemen and slaves.

Whatever, in connection with my professional practice or not, in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret.

While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times! But should I trespass and violate this Oath, may the reverse be my lot!*

*It is worthwhile to comment that whether Hippocrates himself or his followers were responsible for this oath is not entirely clear. For our purposes, we’ll focus more on the content than its historical validity.

Now this is probably the first time you have actually read the full Hippocratic Oath and if not, even better! But a cursory read presents many problems to the present-day Canadian reader reared in a culture of political correctness and championed secularity (see how I pointed out some of our context and how it influences how we read?). Many of us, however, would readily be able to appreciate that our writer intended no malice with these words. We can begin to appreciate that our mindsets were not his paradigm, and this should enable us to read “coolly” without huffing and puffing at whatever we do not like. So first, let’s take a look at our own influences before tackling Hippocrates.

It is not surprising that the oath recited at the white coat ceremony is so far from this ancient oath. There are things in this original oath that modern people disagree with (although this is hardly a reason to hijack the Hippocratic Oath – either let Hippocrates speak as he spoke without twisting his words or stop calling it the Hippocratic oath!). But what is interesting to note is that these disagreements are hardly medical. Hippocrates delves little into technical medicine. The oath revolves more around how to practice medicine and to be moral physicians. We must note here a difference between moral and technical knowledge.

An important distinction between moral knowledge and technical knowledge is that the latter cannot be employed in medicine without the former. We cannot go from “this drug cures cancer” to “give this drug to those with cancer” without a moral injunction. Moral knowledge, which in this case dictates it is good to give a dying patient cancer medication to save his/her life, cannot be found purely in technical data. Some might say it is good to charge an exorbitant price for this drug to make us rich. Others might say it it is good to take a trillion dollar bribe from the man that wants all cancer patients dead instead of offering up the cure. Science does not say it is good to give the drug; it says giving the drug will remove the cancer. What the drug does is technical, but what should be done with the drug is moral, and that takes place at the patient-physician interface called practicing medicine. In other words, science can lead us to the discoveries of new technologies and medicines, but it cannot tell us what to do with what we learn. For some reason it has become popular nowadays to think science can do precisely this, but empirical evidence and theory will never take you there. Remember the humanist optimism of the 19th and 20th centuries that accompanied scientific progress? Remember how it came crashing down with the world wars and we realized technical advancement is not correlated to morality? Giving the cancer cure to dying patients requires moral injunctions.

Furthermore, what makes moral knowledge different from technical knowledge is that the latter changes but the former does not. When we say that medicine has changed over the years, we normally refer to technological and medical advancements. This change does not, however, apply to the moral practice of medicine. Of course there have been different approaches to medicine, such as paternalistic models or counseling models, but at the core what largely makes a good physician today is what made a good physician then. This is why we are able to draw from the Hippocratic Oath at all. Recognition of this distinction between moral and technical knowledge should open us up to learning from all ages about the former (this is not to say it is useless to learn technical knowledge from our predecessors – there is a different kind of merit to this, but that’s another topic!). If we consider what we now understand as massive moral atrocities of societies before us, we should recognize that we are the same biologically with the same propensity for error. We are not superior as people. This will help us learn.

So we have been primed. I will leave it to readers to mull over our approach to Hippocrates (and any history or view different from our own). Real learning actually requires us to think things over and not just amass information – especially when we are dealing with matters of virtue and wisdom, which take decades to properly foster. Sit on this methodology (or blatantly reject it and read no more) and consider your own prejudices a while as I go and consider mine! Let’s be reasonable and honest. More than likely there will be disagreements (and by all means let’s talk about them together in a civil fashion), but good learners will always have an open mind, even to things they initially find bizarre and strange (I wonder how many important things learned in history were initially thought of as bizarre and were initially ridiculed?). This is, after all, the true spirit of genuine and inquisitive science – all questions are up for grabs. Hippocrates was not without his own issues that we will explore next time, but in humility we should consider our own ways of thinking before we consider his. But now that we have established this foundation, the next post can jump into how Hippocrates frames the entire oath and the question of morality… by appealing to all the gods and goddesses!

P.S. If you just had a “Wow, Hippocrates must’ve been a whacko” moment, go back to the beginning of this post and reread everything about what I said about having a good and humble approach!

Ah yes, 4th year. The time when suddenly it becomes real: I’m going to be a doctor. That MD is so close I can pretty much touch the serifs. But before we can bust out singing to Vitamin C (yes, you know the song), there’s still a long trial before us. The long 16 weeks of electives.

Now electives are the shot for us to show off what we have to the various programs and locations across Canada (or even the world if you are so ambitious) that we have the stuff that it takes to be chosen for their program.

Through all the bedlam and rush of these electives, we get the added bonus party time fun of having to write personal statements, update the CV, scrounge together letters of reference, and fill out all the extra redundant paperwork that is required for a CaRMS application.

Yes Natasha, I agree.

However, if we let ourselves take a step back from the daily double grind of working while being on show, move past the exhaustion from the long days, and separate ourselves from the stress of the applications, these elective times are great opportunities. They’re a time to really show off to yourself how far you’ve come. They’re an amazing opportunity to adventure through and live in (albiet VERY temporarily) different places. And you’re likely going to meet a bunch of new people who may become future co-residents, colleagues, or friends.

As the three quarter mark is approaching for the current elective tour, I thought it would be a great time to sit back and reflect on some of the subtler lessons I learned from the long haul.

1) Pack light, travel quickly (alternate title, scrubs are the best)

In one of my favorite movies, Up in the Air, George Clooney poses this question at the beginning of his seminars “What’s in your backpack?“. While his speech is focused on the metaphorical baggage that bogs a person down in everyday life, it’s a good prompt to examine the actual physical baggage that can encumber your peripatetic lifestyle during this year.

From one standpoint, it’s more economical: the airlines have recently implemented more fees for check-in luggage and driving around with heavier loads will also hike up your vehicle’s fuel costs. From another, it’s also easier to move around, you need less time to pack, and it frees up some of the clutter.

Which is why scrubs are awesome because I’ve pretty much cut down two-thirds of my clothing needs as a result. Plus you can look like a ninja at work, which is awesome.

For those without the luxury of having the scrubs option at work, there are still other ways to lighten the load. Simplifying outfits, or finding multifunctional pieces are one way. Eliminating excessive electronics, books, or other accessories are all options as well. Personally I thought that I was traveling pretty efficiently already but after my first couple electives I realized I still did not use a good chunk of what I packed. With my next stopover at home, I hope to be able to make like a bro in summer and cut down the excess bulk.

2) When in a new city, make friends with a local and do what they do

So you’re in a new city and like any good medical student you’ve done your research. You’ve never been to Toronto, Calgary, Halifax, or Vancouver (etc etc) before and want to see all the attractions (and more importantly eat all the food) before you fly out 2 weeks later (come to think about it, visiting medical students are kind of like a pack of cicada – we swarm in, drum up a bunch of cacophony, eat a whole bunch, and in a couple weeks of annoyance to the locals we’re gone).

Yeah, that’s a lot of fun and be sure to take part in it, there’s a reason why those places become the hotspot.

But at the risk of sounding a bit too hipster, it’s better to make friends with some locals or inquire a classmate who is a local and get tips from them.

Why? Well, A) they may have better knowledge on which places are worth the hype and which aren’t. This leads to much better use of your limited time. Secondly, they probably know some other up and coming trendy places that may not be listed on Fodor’s. Finally, locals can probably offer tips that make your day-to-day life on elective easier. You know, stuff like helping figure out transit routes, good places for groceries, and what you might need to bring before heading to the city.

In essence, utilize those interviewing skills you picked up in clinical sessions and strike up a conversation with a local.

3) There are a million “absolute right way” to do a simple procedure

From suturing, approaches to presenting a case, to even taping people’s eyes, you’re never doing it right. On day one you might get a nice lesson on how to approach intubating a patient. Great, you think, I’ll just do it like this with the next few docs here and I’m set. Day two, your doc looks thoroughly unimpressed with your “technique”, even though you did the exact same thing as the other attending.

Great, don’t tell me this is your first time intubating. You’re doing it all wrong! and you get another lesson, which will only be corrected by the next guy.

Repeat ad nauseum to every elective and every physician you encounter along the way. It’s like facing Tyson for the first time on Punch-Out: you cannot win. I feel like you simply got to go with it, and take solace in the fact that you’ll likely do it yourself once you got medical students of your own to “teach”.

b) You need wifi to either work on applications or go on social media (or blogs) to procrastinate from working on applications.

c) You consume a large amount of sugar/carb dense snacks to compensate for the lack of sleep you get.

d) All of the above.

The coffee shop provides all of these amenities, making it the natural stronghold of the traveling medical student. The trick is finding a good one to bunker down in when you’re in a new city. A good coffee shop will cover the basic necessities of survival: protection from the elements whether it’s rain, snow, or the cold; a means of communicating with others via a strong wifi connection, hydration in terms of coffee/tea/beverages; and food in terms of an assortment of baked goods.These are the basics, and everyone has their own personal preference on what they value more. For me, it’s the wifi. Sometimes I can’t count on the connection at the accommodations I’m staying at and I need to get online to work on CaRMS. But that’s just me.

Every hospital will run slightly differently. There’s a lot of desire, especially at first to try to jump right in and look like a star off the bat. I would recommend against that. Seriously.

There’s no rush and it’s better to be a fly on the wall and watch what happens, ask the right question, and ease into it. People like to welcome the rookie and it’s pretty favorable to appear as the person who fits in well seemlessly and remembers all the veterans’ advice.

Don’t worry if you don’t try to jump in. It’s just too confusing and stressful trying to figure out a hospital’s way of doing things before you really even have been there. Each are it’s own beast. And it doesn’t matter if you might look bad in front of someone stumbling around lost the first few days. Sorry to burst that bubble but you’re pretty forgettable.

6) When it comes to accommodations – location, location, location!

Electives can be pretty expensive, from application fees, gas fees, air fare, and costs of living. And even though you’re expected to be in the hospital and clinic for most of the day, you actually won’t be allowed to live in one while you’re visiting.

Bottom line: you need to find a place to live.

Now generally the options are: rent/sublet from someone (usually another medical student or resident), find a friend, or stay with family. A lot of people go with the options of staying with friends and family to save cost or to have a good time. But I feel the most important aspect of choosing your lodging is location.

The key number is 15 – that is minutes or less from your main hospital/clinic/centre. The main reason for that is it’s close enough you can escape the clutches of the hospital quickly, but that also means you can get to the hospital quickly when you need to. This is beneficial when you want to come in early in the morning, if you want to get a few more minutes of rest or have a long morning routine, or (if you’re close enough) even having a place to retreat to on a night of call that isn’t a stuffy room with a molded plast mattress.

Having paid for a place right next to the hospital and having saved money by staying at home and commuting, I still say the location is worth missing out on the free meals and cheaper save. Over time, the earlier mornings due to the commute and having to still spend up to an hour getting home after work is done just adds up and cuts into your productivity.

7) Never turn down offers from physicians

While they may be strangers to you, you shouldn’t turn down offers from any of the physicians you meet while on electives, especially if it’s candy. Often these offers come up innocuously, and have a very short time period to respond. So are you in? And while that answer yes might not always be crazy, memorable, the hospital turning into a bumping club, adventures, there is often some benefit awaiting, even if there might seem to be some work involved in it.

Help out with a report? Sure that’s a bit of work, but you can get published and it makes a good impression with the residents.

In the end the electives are not only a chance for you to demonstrate that you’re a great potential resident to each program, but it’s an amazing opportunity for you do tailor your education independently. While it can be a lot of fun to play tourist, go out and eat fun meals, and travel, it ultimately comes back to have the freedom of 16 weeks for you to pick up additional skills for your future as a ______this spot left intentionally blank________ physician.